Pakikisama: Filipino patient perspectives on healthcare access and utilization

Abstract

Purpose

Filipinos have unique social determinants of health, cultural values, and beliefs that contribute to a higher prevalence of cardiovascular comorbidities such as hypertension, diabetes, and dyslipidemia. We aimed to identify Filipino values, practices, and belief systems that influenced healthcare access and utilization.

Methods

We conducted 1-on-1 semi-structured interviews with self-identified Filipino patients. Our qualitative study utilized a constant-comparative approach for data collection, thematic coding, and interpretive analysis.

Results

We interviewed 20 Filipinos in a remote rural community to assess structural and social challenges experienced when interacting with the healthcare system. Our results suggest that Filipinos regard culture and language as pillars of health access. Filipinos trust providers who exhibited positive tone and body language as well as relatable and understandable communication. These traits are features of Pakikisama, a Filipino trait/value of “comfortableness and getting along with others.” Relatability and intercultural values familiarity increased Filipino trust in a healthcare provider. Filipinos may lack understanding about how to navigate the U.S. healthcare system, which can dissuade access to care. Reliance on family members to serve as healthcare navigators is a common practice but is not the standard of care.

Conclusions

When serving the Filipino community, culture and language are fundamental components of health access. Healthcare systems have the opportunity to both improve intercultural clinical training and increase representation amongst providers and support staff to improve care delivery and navigation of health services.

INTRODUCTION

Filipino-Americans and Filipino immigrants combined make up the third largest Asian subpopulation in the United States¹. Like other minoritized populations in the U.S., Filipinos experience significant health disparities; in one study of diabetes prevalence in Asian subgroups in the U.S., 32% of Filipino patients were identified as having diabetes, compared to only 23% of Asian patients overall, and 13% of non-Hispanic White patients². Because most current health equity and outcomes research and data collection practices commonly aggregates Filipinos with other Asian subgroups, little is known about factors contributing to these health inequities or strategies to address them³. Filipino cultural values, practices, and belief systems are a contributing factor in the development of cardiovascular illnesses and may play an important role in healthcare access and utilization⁴. Providing culturally sensitive care can improve overall health outcomes for marginalized populations⁵, including Filipino immigrants and Filipino-Americans who lack understanding of the health system⁶.

The overall objective of this qualitative research study was to assess the facilitators and barriers to healthcare access among Filipino Americans and Filipino immigrants in a remote rural community in Alaska, The findings from this study will provide critical contextual information about cultural and systemic challenges in how Filipinos experience and access healthcare. Findings may be useful to guide health systems seeking to implement changes that will improve access to care for Filipino American and Filipino immigrant communities.

METHODS

Study Design

This health equity-informed qualitative study aimed to understand how Filipinos perceive and experience healthcare in a rural community. We conducted semi-structured interviews with Filipino Americans and Filipino immigrants and performed qualitative thematic analysis of interview transcripts, using a constant comparative method. The interview script used open-ended questions to identify cultural and perceived patterns of healthcare seeking behavior and built on initial factors affecting healthcare access identified by a 2019 Filipino Community Health Survey conducted by Ketchikan Public Health Department. Our interview script assessed facilitators and barriers in the domains of healthcare cost, accessing care (with regards to transportation, language, and perceived barriers), trust (in the local healthcare system as well as trust in an individual provider), and cultural factors (i.e., spirituality, cultural norms, and practices). The study protocol and ethical considerations were approved by the PeaceHealth Institutional Review Board.

Setting

Our study was conducted in a remote rural community (Frontier and Remote Area Category 2, Rural Urban Continuum⁷ Code 7) in Southeast Alaska. At the time of this study, the Filipino community was estimated to be 6.7% of the total population of approximately 8,000 residents (9.5% when including Filipino mixed race). The local healthcare system is comprised of multiple independent primary care clinics and a Critical Access Hospital with an embedded primary care clinic.

Participants

Eligible individuals were those who self-identified as Filipino, self-reported living in the area, and self-reported having had one or more encounters with the local healthcare system in the last two years. The local Filipino community includes recent and established immigrants as well as Filipino-Americans born in the United States. No participants were excluded on the basis of primary or preferred language.

Recruitment

Participants were identified through an in-person Filipino community event conducted in October 2021. At the event, a member of the research team distributed flyers about the study. Information about the study was also shared via social media and word-of-mouth. Interested individuals were contacted after the event and offered an opportunity to enroll. Participants were also asked to recommend peers for participation using a snowball recruitment method. Recruitment of the study population was purposeful to ensure a diverse sampling was achieved (i.e., gender, age, occupation, and site of primary care). Participation was voluntary and those who completed the interview were compensated with a $40 gift card for a local vendor.

Data Collection

The interview guide was designed to explore challenges and barriers with respect to U.S. healthcare cost and access in addition to Filipino cultural factors affecting health (Table 1). The interview guide was pilot-tested with a member of the Filipino community prior to formal data collection, which was then reviewed by the study team to refine the open-ended questions.

Table 1.

Interview script for key-informant interviews.

Health care cost

Tell us about your experience accessing health care in Ketchikan. How has the cost of health care affected how you seek care? Have you experienced any challenges with medical bills? And if yes, please tell us more about what was difficult?

Accessing care (Transportation, Language, etc.)

Have you faced any challenges that have impaired your ability to seek medical care? (for example, transportation, interpretation services, etc.) Can you tell us about the experiences you’ve had communicating your health concerns? What has gone well and what has been difficult? Have you had experience needing to use interpreter services at your health care provider’s office? If yes, what was the experience?

Trust & perceived fear

What factors affect your ability to trust a health care provider? Do you have any fear about various medical conditions or learning new information about your health? If yes, tell us more about those fears?

Culture, religion, and spirituality

What do you think are the defining factors of the Filipino community? What strengths of the Filipino community contribute to your overall health? Does religion or spirituality play a role in your overall health? Have you experienced racism and bias when receiving health care? If yes, can you share more about that experience(s)? How do you think consuming typical Filipino food has contributed to your overall health?

From April to June 2022, semi-structured one-on-one interviews (n=20) were conducted face-to-face in participant’s preferred language. All participants selected English as their preferred language for participation. Each interview lasted between 15–60 minutes. All 20 participants provided verbal informed consent prior to the interview. Participants varied in age, gender, and recency of immigration (data not shown). The interviewer was a member of the local Filipino community and an experienced community outreach professional. All interviews were audio-recorded and transcribed for review by the coding team. Interviews were conducted until saturation for identified themes was reached, and the team determined additional interviews were not yielding further insights.

Data Analysis

Transcribed interviews were deidentified and provided a unique identifier (e.g., 1–20). Initial data analysis began after the first two interviews were completed and ongoing analysis was completed in real time as data was collected. Interviews were thematically analyzed using a team-based constant comparative method. We developed a codebook inductively utilizing an emergent coding approach based on our interview guide. The final codebook was tested on two randomly selected transcripts and resulted in an intercoder reliability of 89%. Four researchers continued coding the remaining 18 transcripts, with two researchers (J.C., C.J.) coding all transcripts and four coding five transcripts each (R.L., A.P., A.C., and L.M.).

Transcript excerpts were organized by their respective consensus codes and were then reviewed in a group setting with the entire research team. Initial meetings focused on reconciling coding discrepancies and subsequent sessions focused on deriving cross-cutting themes. Researchers synthesized groupings of themes extracted from coded transcript excerpts. Further descriptive analysis resulted in three cross-cutting themes each relating to how Filipinos experience and access healthcare (Figure 1).

Figure 1: Deriving cross-cutting themes.

RESULTS

We identified three cross-cutting themes related to facilitators and barriers to healthcare access, derived by a constant-comparative approach: (1) Culture and language influence healthcare access, (2) Relational, community-based care experience, (3) Structure of current healthcare system creates barriers to accessing care.

1. Culture and Language influence healthcare access

We identified several aspects of Filipino culture and language that influence healthcare access. Filipinos share a sense of duty that prioritizes the needs of others in the community before themselves.

“We care for each other. We give advice to others. We help, we share what we have. That’s good. They bring food. We bring food. That’s why we are happy.” (#6, 4.26)

We found that younger individuals report that they assist with bridging cultural and language differences between older Filipinos and the healthcare system. Younger family members reported serving as healthcare navigators for their elders.

“I’m trying to think, mainly the interpretation, especially with medical, um, but a lot of my family they kind of understand and they’ll, they’ll bring, um, my mom, my mom” (1973, 6.27)

Participants reported that when they do seek healthcare, clear communication and Pakikisama, or a “feeling of comfortableness,” with the healthcare provider were important positive qualities that helped promote healthcare access. Access is viewed as not only being able to see a provider, but also being “understood” by that provider. The cultural value of Pakikisama, which conveys that a person belongs to a group and there is a value placed on being dedicated to that group. Participants described putting the needs of others before self as a factor in delaying access to care for themselves or not accessing care at all (Table 2).

Table 2.

Participants quotes organized by cross-cutting themes

Culture and language: as a feature of access

“I do believe [Filipinos] are very hard working and dedicated to their families, and stubborn, especially, [when it comes to] taking of themselves. [Filipinos] would take of other family members before themselves. [They] are friendly, warm, caring, and it comes from everywhere depending on the family dynamics. They would rather take care of everyone, make sure everyone [else is] healthy and fed, before themselves.” (#18, 5.24) “I work two jobs and so I have problems with that, but now with the medicine that they [prescribed] makes me feel good.” (#19, 6.27) “[It’s] a cultural thing. I feel we’re hard workers and we try and strive to put money aside so we could have food on the table, shelter over our head and things like that. So, I can see why health can be put on the back burner.” (#16, 5.24) “We care for each other. We give advice to others. We help, we share what we have. That’s good. They bring food. We bring food. That’s why we are happy. (#6, 4.26) “As I got older, the fear [that] a lot of Filipino families have is this fear of going to hospitals, whether it’s just the fear [overall] or the fear of the language barrier, the fear of the medical bill or what. Especially [for families] coming over from the Philippines, there’s not enough education[al] information [about when] teenagers or girls should be going in for their annual appointments or things such as birth control. Those are just things I feel like in most households are topics that are avoided. These girls either learn about it on their own or they just, they just don’t learn about it at all. [In] my experience growing up, that’s something that was missing. [Things like] birth control and annual appointments weren’t spoken about in my household. I just figured [that stuff] out on my own. Even my mom was shocked when I did start taking birth control [after high school even though I was older].” Especially when our culture, [even though] many of us grew up in the United States, we see our families, or our parents and the older generation really find it very taboo to talk about sex education or birth control or even understanding the menstrual cycle.” (#16, 5.24)

Relational, community-based care experience

“I just like the way my [doctor] comes off, he comes off pretty friendly and makes you feel comfortable just by engaging in regular conversations sometimes. It’s not all about what’s ailing me. [The visit] is a little more personal, [with time to be] able to talk and just make me feel comfortable. [Even when I was given the option to transfer to a Filipino Tagalog speaking physician], I declined because I was more comfortable just staying with him and [we have a] good relationship.” (#10, 5.18) “But overall [the healthcare providers I’ve seen have] been very helpful. They’ve been very accommodating and it’s usually not just business with them. [They always ask] ‘Hey, how’s it going?’ Small talk is not necessary, but it definitely helps you get to know what’s actually going on versus what you think’s going on.” (#15, 5.24) “There are just some [physicians] whose answers are more real, [and who give more] real world answers than the medical aspect of it. They try to make things very relatable and understand[able].” (#16, 5.24) “My provider is very thorough, and she doesn’t seem like she’s rushing through questions that I have. She understands my preferences when it comes to medication or care. And she takes her time.” (#18, 6.27) “I [saw one] physician throughout all my adult life, then I realized, you can change physician if you don’t see eye to eye with how [they] explain certain things. My physician didn’t get what I was trying to address, so I changed over to a new physician and I felt he understood what I was trying to [convey]; I think it was just a communication factor. He was my age and understood what I was going through. So, it was easier for me to just to open up.” (#2, 4.20) “With my new physician now, I feel that he gets it. When I see him, it feels like he understands. There’s a relationship that is just more comfortable for me to tell him what I exactly want or need.” (#2, 4.20) “I changed my doctor because she didn’t understand me, or I didn’t understand her because her suggestion was to come back again if the [issue] ever becomes big again.” (#8, 5.05) “A lot of it has to do with how they speak to you and how address your concerns. Because going to the doctor can be scary and a lot of it is kind of overwhelming because it’s your body and it’s your health. It can be very complicated if the doctor or even the front desk people that you’re trying to work with are not being very endearing when you’re scared and it’s your health and you just want to make sure that you’re okay. A lot of people don’t like to go to the doctor anyways and like me, I don’t really particularly like going to the doctor. So, without that extra sense of security and extra sense of calmness, I think it’s really hard to want to go to the doctor. (#11, 5.18)

Structure of current healthcare system as a barrier to accessing care

“[My friend] went [to the ER] and the next thing he has like a $1500 bill (laughing). Right now [he still has a] $100 balance… That’s how [the] hospital works. You know, when you see a doctor, even if you don’t do anything [you get charged] a lot.” (#3, 4.25) “I have a huge bill, so yeah, that’s my biggest challenge….” (#8, 5.05) “My insurance takes care of a lot of it, but it also gets pretty expensive every month.” (#10, 5.18) “When I do my mammogram [and other women’s care], I have to pay extra aside from my insurance… Sometimes [I ask] for [financial assistance through the hospital] or I can … just pay it monthly.” (#8, 5.05) “Everything was clear… when I went to check out up front, [the girls] up front also gave me the information of who to call regarding [the cost] out of pocket [for treatment] … so it’s like, I got the full 360 of what needs to be done after my business, everything was taken care of. I left knowing what I need to do and how to do it.” (#9, 5.17) “I have never used the interpretation services at the doctor’s office, and I didn’t know they had this available.” (#12, 5.19)

“I do believe [Filipinos] are very hard working and dedicated to their families, and stubborn, especially, [when it comes to] taking of themselves. [Filipinos] would take of other family members before themselves. [They] are friendly, warm, caring, and it comes from everywhere depending on the family dynamics. They would rather take care of everyone, make sure everyone [else is] healthy and fed, before themselves.” (#18, 5.24)

“[It’s] a cultural thing. I feel we’re hard workers and we try and strive to put money aside so we could have food on the table, shelter over our head and things like that. So, I can see why health can be put on the back burner.” (#16, 5.24)

Participants reported barriers in speaking about matters of health that are perceived as sensitive or private, for example reproductive healthcare.

“Especially when our culture, [even though] many of us grew up in the United States, we see our families, or our parents and the older generation really find it very taboo to talk about sex education or birth control or even understanding the menstrual cycle.” (#16, 5.24)

2. Relational and community-based care experience

Participants reported that they value trusting and positive relations with a healthcare provider. Individual experiences with healthcare are often shared amongst the community. In turn, these experiences and stories serve as guidance for other Filipinos in the community considering seeking healthcare.

“There are just some [physicians] whose answers are more real, [and who give more] real world answers than the medical aspect of it. They try to make things very relatable and understand[able].” (#16, 5.24).

Participants highlighted that feeling heard and understood were positive features that helped determine how they select and why they stay with a particular primary care provider. A “relatable and understandable” style of interaction was valued, both explicit in the style of speech and implicit in the overall tone and open body language.

“It’s usually not just business with them. [They always ask] ‘Hey, how’s it going?’ Small talk is not necessary, but it definitely helps you get to know what’s actually going on versus what you think’s going on.” (#15, 5.24)

Other factors that contributed to trust and rapport included: personable qualities, familiarity of language and culture, and appropriate clarity of communication.

“I changed my doctor because she didn’t understand me, or I didn’t understand her because her suggestion was to come back again if the [issue] ever becomes big again.” (#8, 5.05)

“[Even when I was given the option to transfer to a Filipino Tagalog speaking physician], I declined because I was more comfortable just staying with him and [we have a] good relationship.” (#10, 5.18)

Some participants cited a higher degree of trust with Filipino caregivers due to similarities in language and culture. This was especially noted if both the patient and the healthcare worker shared ties to a geographical area or shared language.

“I [saw one] physician throughout all my adult life, then I realized, you can change physician if you don’t see eye to eye with how [they] explain certain things. My physician didn’t get what I was trying to address, so I changed over to a new physician, and I felt he understood what I was trying to [convey]; I think it was just a communication factor. He was my age and understood what I was going through. So, it was easier for me to just to open up.” (#2, 4.20)

Research participants described more positive experiences with providers when relational caregiving was present. Providers who were more transactional or ‘by the book’ were perceived less positively. Participants described the importance of connecting in a relational way and how that came across in interactions. For example, one participant said,

“A lot of it has to do with how they speak to you and how address your concerns. Because going to the doctor can be scary and a lot of it is kind of overwhelming because it’s your body and it’s your health. It can be very complicated if the doctor or even the front desk people that you’re trying to work with are not being very endearing when you’re scared and it’s your health and you just want to make sure that you’re okay. A lot of people don’t like to go to the doctor anyways and like me, I don’t really particularly like going to the doctor. So, without that extra sense of security and extra sense of calmness, I think it’s really hard to want to go to the doctor. (#11, 5.18)

3. Structure of current healthcare system a barrier to accessing care

The structure of healthcare in the U.S., from payment structures to reimbursement models, and the interface between the healthcare system and consumers can create barriers to access for Filipino patients. Participants described cost of healthcare as a significant burden.

“[My friend] went [to the ER] and the next thing he has like a $1500 bill (laughing). Right now [he still has a] $100 balance… That’s how [the] hospital works. You know, when you see a doctor, even if you don’t do anything [you get charged] a lot.” (#3, 4.25)

When patients received clear and supportive information about healthcare costs, they reported positive feelings towards healthcare.

“Everything was clear… when I went to check out up front, [the girls] up front also gave me the information of who to call regarding [the cost] out of pocket [for treatment] … so it’s like, I got the full 360 of what needs to be done after my business, everything was taken care of. I left knowing what I need to do and how to do it.” (#9, 5.17)

Participants reported that interpreter services are not always routinely offered or being unaware of the availability of interpreter services.

“I have never used the interpretation services at the doctor’s office, and I didn’t know they had this available.” (#12, 5.19)

DISCUSSION

Primary Outcomes

We found that healthcare access encompasses and is influenced by features of both culture and language. Filipinos rely on family members as healthcare navigators when there is a baseline discordance of culture and language between a patient and provider/healthcare system. Healthcare in the Filipino community prioritizes the relational experience between patient and provider/healthcare system. Trust is a fundamental component of relational care and is defined by relatability, clarity, and familiarity. Filipinos cited higher trust in providers with positive implicit (i.e., tone, body language) and explicit (i.e., relatable and understandable communication) qualities. Participants also reported higher trust with providers and caregivers who acknowledge their cultural background, beliefs, and practices. High healthcare costs and lack of price transparency may inhibit many Filipinos from seeking care. While interpreter services are the standard of care for intercultural communication in the primary care setting, the variability in availability and use of services means few experience the benefits of these services.

While the U.S. medical system commonly interprets healthcare access as the ability to provide timely, high-quality services⁸, equitable access for immigrants also requires healthcare system cultural competency and language accommodation^{9, 10,} Our findings are consistent with current research supporting the notion that race and cultural concordance increases the likelihood that an individual will seek care and may improve health outcomes^11–14. In our study, Filipinos and Filipino Americans identified the Filipino trait called Pakikisama (“getting along with others¹⁵”) that is important in garnering trust from patients. Pakikisama applies to the friendliness and relatability of a provider³. Interpersonal competencies and professional attributes that help develop trust with patients are training priorities for practicing providers and medical trainees^16,17. Health systems may also consider focusing recruitment of providers and staff on those that better reflect the demographic distribution of their local population. Cultural representation may increase trust in the healthcare system¹⁸ and in turn may maximize primary care utilization¹⁹. Trust in the primary care setting may decrease preventable utilization of high cost services^20,21 (i.e., emergency department visits and inpatient admissions).

Our findings support the need to improve language accommodations in the clinical setting. While interpreter services are the standard of care, we found that Filipino and Filipino American participants were unaware of the service availability, perhaps because the interpreter serves are not routinely offered, or they may not provide nor have the access to the proper Filipino dialect. Rural health systems report significant barriers in offering and provider interpreter services²². This is especially important given that the high prevalence of English proficiency among Filipinos may mask communication challenges¹ (i.e., difficulty communicating feelings, symptoms, as well as intimidation). Elderly individuals and recent immigrants are more likely to experience language barriers in healthcare²³. These sub-populations are known to have more limited English proficiency, less education, and lower perceived cultural understanding¹.

Differences between the U.S. and Philippine healthcare systems may create barriers to access. Filipinos are accustomed to either a social health insurance program, in which all residents can access care²⁴, or a private cash-for-service payment system. Unfamiliarity with costs and payment in the U.S. healthcare system may dissuade individuals from seeking care in the U.S. We found that participant experience with unanticipated and high ER costs negatively impacted access in the communities. These anecdotes may permeate to other members of the Filipino community, discouraging others from seeking care. Promoting hospital-based financial assistance plans (“financial assistance”) may improve healthcare access for populations experiencing disparities, which often have a higher prevalence of uninsured or underinsured individuals.

In our study, family members or close friends operated as patient navigators or support figures to help participants with limited language capabilities and less experience navigating the healthcare system²⁵. Race and language concordant patient navigators have been shown to improve timeliness and access to care²⁶ and may be a useful strategy for meeting the healthcare access needs of Filipino and Filipino American populations without burdening family members and caregivers. Healthcare systems may consider improved care coordination and recruitment of multicultural staff into navigator roles²⁷.

Strengths and Limitations

Our results shed light on important and unique access to healthcare barriers faced by Filipino and Filipino American patients in a rural community. These findings may be applicable to medical practices serving multicultural populations^{28, 29} (i.e., Latinx and Native American or Alaska Native communities). Additional strengths of our study include robust community partnerships embedded into our study design. Partnering with a community organization allowed participants to provide frank information about healthcare. While the principal investigator of the study was a healthcare provider in the community, interviews were conducted by a study team member unaffiliated with the local healthcare system to minimize response bias.

Our findings may be limited by the self-selection of participants, as we may not have fully assessed perspectives of non-participants such as those with multiple jobs and family obligations precluding their ability to invest time in an interview. We recognize that the experiences of Filipino immigrants in a frontier community may not represent the experiences of all Filipino immigrants/Filipino Americans in the United States. Many participants provided additional commentary after ending the official interview, indicating that the population may have felt more comfortable sharing information outside of a formal recorded setting. These data were not included in our analysis. We also collected and analyzed data pertaining to faith, nutrition, women’s health, and culturally taboo topics not fully included in this study.

Conclusions

Reframing healthcare access to include intercultural factors may help improve health outcomes for Filipino communities. Acknowledgement of patient cultural values can foster higher levels of trust in the healthcare system, which is a fundamental component of relational care to Filipinos and can improve health utilization patterns. The current healthcare system is challenging to navigate for Filipino immigrant populations; and despite not being the standard of care, there is an overreliance on family members to serve as healthcare navigators and interpreters.